Laparoscopic Roux-en-Y gastric bypass after Nissen procedure for morbid obesity

Different studies have shown that revision of antireflux procedures to RYGB is safe and feasible for morbidly obese patients with weight gain or recurrent GERD symptoms. This video demonstrates a laparoscopic gastric bypass in a 56-year-old patient who had benefited from a laparoscopic Nissen fundoplication in 1999. The patient presents with a BMI of 40 and a diabetes mellitus resistant to treatment.

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Laparoscopic Roux-en-Y gastric bypass after Nissen procedure for morbid obesity

Authors

F Costantino, B Dallemagne, J Marescaux

Abstract

Different studies have shown that revision of antireflux procedures to RYGB is safe and feasible for morbidly obese patients with weight gain or recurrent GERD symptoms. This video demonstrates a laparoscopic gastric bypass in a 56-year-old patient who had benefited from a laparoscopic Nissen fundoplication in 1999. The patient presents with a BMI of 40 and a diabetes mellitus resistant to treatment.

Keywords

Laparoscopic, Roux-en-Y, gastric, bypass, Nissen, morbid, obesity

Media type

Surgical video

Duration

13'28''

Publication

2010-11

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E-publication

WeBSurg.com, Nov 2010;10(11).
URL: http://www.websurg.com/doi-vd01en3116.htm

Laparoscopic Roux-en-Y gastric bypass after Nissen procedure for morbid obesity

1. Introduction 00'16''

This video demonstrates a laparoscopic gastric bypass in a 56-year-old patient who had benefited from a laparoscopic Nissen fundoplication in 1999. The patient presents with a BMI of 40 and a diabetes mellitus resistant to treatment.

2. Exploration and Nissen wrap taking down 00'34''

Trocars are placed in a conventional fashion. Exploration is carried out at the level of the Nissen wrap, which will be taken down. The intervention is performed at the level of the adhesions situated between the stomach and the left inferior border of the liver. Sutures used in the previous Nissen fundoplication are identified. These stitches allow for dissection over the planes of the scar tissue resulting from the Nissen procedure. Several adhesions are freed. This allows for the identification of the anatomical landmarks, namely the Nissen wrap and the crus situated to the left of the hook. The crus has already been dissected, which facilitates this step of the intervention. A new suture fixed towards the right crus of the diaphragm can be observed.

3. Retrogastric passage 02'39''

Once the wrap has been taken down, attempts to obtain a retrogastric passage at this level are made. Blunt maneuvers and monopolar cautery at 15 Watts are used here in order to avoid any thermal lesion. Retrogastric passage is achieved through both crura.

4. Left flap freeing 03'14''

The flap of the left wrap can be seen here. Its transgastric and transesophageal passage will be taken down using monopolar cautery. The freeing is carried on. The posterior flap, which has numerous adhesions between the esophagus, the stomach and both diaphragmatic crura, is introduced physiologically. Coagulation is carried out progressively in order to avoid bleeding, thus allowing to completely free the flap and to place it in an orthotopic fashion. Adhesions situated at the level of the short vessels are freed, the latter having been mobilized in the previous Nissen procedure. Now the anatomical landmarks can be freed.

5. Tape placement and traction 04'24''

In order to carry on the dissection at the level of the diaphragmatic crossing, a tape is placed for traction purposes. The intervention is pursued between the first and the second right gastric vessels in order to gain access to the lesser sac, controlling the vessels towards the insertion on the lesser curvature.

6. Lesser sac opening 05'03''

Once the lesser sac has been opened, the posterior aspect of the stomach can be explored. The healthy tissue will be delimitated and divided.

7. Beginning of gastrectomy 05'22''

A 60mm linear stapler, blue cartridge, is used to perform a purse-string, which allows to carry out an horizontal cut. A vertical cut is then performed just at the level of the intersection of the suture lines. At this step of the intervention, the help of the first assistant is needed so that a good quality division line can be achieved. In order to prevent the formation of any posterior gastric pouch —a very common error when performing this type of surgery—, a posterior passage must be obtained at the level of the esophagogastric angle during the dissection. This step of the intervention is of high importance. A second and a third application of the 60mm linear stapler are performed in order to carry out the gastrectomy safely.

8. Suture line reinforcement 06'41''

A non-absorbable monofilament suture is carried out at the level of the suture line by means of PDS 3/0 material. This type of suture allows to bury it. Although it has not proved to avoid fistulae or any other potential complication, it is our conviction that the hemostatic control of the suture line is much safer by using a running suture. A running suture is placed over the gastric pouch until the crossing of the horizontal suture line and the beginning of the vertical one, since a gastrojejunal anastomosis will be performed using a circular stapler.

9. Gastrotomy and purse string performing 07'57''

A small gastrotomy is carried out and a 25mm PCEEA circular stapler is introduced orally. A purse-string is performed in order to obtain a compact tissue at the level of the anastomosis. This suture is achieved by means of a PDS 3/0 monofilament thread. An external knotting system created by Professor Leroy is used.

10. Jejunojejunal side-to-side anastomosis 09'01''

Once the supramesocolic procedure has been completed, access is gained to the inframesocolic space. A length of 70cm is measured at the level of the duodenal loop, which is fixed to the round ligament. The duodenal loop is marked. This length is then measured 150cm away from the duodenal loop. A transitory fixation is carried out at the level of the duodenal and common loops, thus allowing to place traction and to perform a side-to-side anisoperistaltic anastomosis. Traction is exerted on the duodenal and common loops. An enterotomy is performed in both loops. A 60mm linear stapler, white cartridge, is introduced. It will allow for a perfectly safe anastomosis. A firing is then applied and the intestinal defect is closed by placing a PDS 3/0 absorbable monofilament running suture. A stitch is placed at the inferior angle of the mesenteric defect, thus allowing for a perfect traction at the level of its superior angle and for a perfect closure of the abdominal defect. The anastomosis is carried out using a running suture. The suture placed at the inferior angle is then knotted. The mesenteric defect is closed, thus avoiding passage inside the small bowel and any potential internal occlusion during the postoperative period.

11. Alimentary loop division 12'07''

The division stitch is removed in a transitory fashion and the intestinal loop is divided, thus becoming the alimentary loop. This is achieved by means of the 60mm Endo-GIA linear stapler, white cartridge. Vascular control of the alimentary loop is carried out. An enterotomy is performed using the Ligasure® vessel-sealing device. A 25mm circular stapler is introduced though the abdomen. The intestinal perforation is achieved.

12. Gastrojejunal anastomosis 12'54''

The gastrojejunal side-to-side anastomosis is carried out by means of this circular stapler.

13. Methylene blue test 13'50''

A methylene blue test is performed. It shows no leakage. The good condition of the suture line is controlled. The division of the caecal loop is carried out by means of the 60mm Endo-GIA linear stapler, white cartridge.

14. Petersen’s space closure 13'31''

The procedure is completed by closing Petersen’s space using a non-absorbable, external knotting 3/0 monofilament thread.